GOOD MORNING

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AIR WAY MANAGEMENT

CH.VENKATESWARARAO 2nd MDS

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Anatomy of Respiratory System

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Upper Respiratory Tract

Composed of the nose and nasal cavity, paranasal sinuses, pharynx (throat), larynx. All part of the conducting portion of the respiratory system.

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Pharynx

Common pathway for both air and food. Partitioned into three adjoining regions: naso pharynx oropharynx laryngopharynx

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Lower Respiratory Tract

Conducting airways (trachea, bronchi, up to terminal bronchioles). Respiratory portion of the respiratory system (respiratory bronchioles, alveolar ducts, and alveoli).

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Larynx
Voice box is a short, somewhat cylindrical airway ends in the trachea. Supported by a framework of nine pieces of cartilage (three individual pieces and three cartilage pairs) that are held in place by ligaments and muscles.

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Patient assessment and preparations

1. 2.

History Physical examination

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The Ritual of the Seven Ps of RSI 1. PREPARATION 2. PRE-OXYGENTATION 3. PRE-TREATMENT 4. PARALYSIS with Induction 5. POSITIONING 6. PROVE PLACEMENT 7. POST-INTUBATION MANAGEMENT

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In assessing patient 4 areas should be evaluated for signs that may suggest difficulty. 1. Limited volume or displacement of tongue during laryngoscopy. 2. Limitation to inserting laryngoscope or obtaining straight line of sight to the glottis. 3. Limitation of mouth opening:

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Anesthesiology, V 98, No 5, May 2003

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AIRWAY ASSESSMENT:
Mallampati classification
Uvula

In Samsoon and Youngs modification (1987) 3 of the Mallampati Wednesday, February 06, 2013 classification, a IV class was added.

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AIRWAY ASSESSMENT:
It involves measuring the distance between the thyroid notch and tip of the jaw The thyromental gap Thyromental gap < 6cm Difficult airway 6-6.5 Might be less difficult >6cm Normal airway
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Patil test

Cormack and Lehane

Grade I: most of glottis is seen Grade II: only posterior portion of glottis can be seen. Grade III: only epiglottis may be seen (none of glottis seen Grade IV: neither epiglottis nor glottis can be seen

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grade 3,4 - risk for difficult intubation

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SAVVA, Sterno-mental distance,

The distance from the suprasternal notch to the mentum and investigated Mallampati class, Jaw protrusion, Interincisor gap and Thyromental distance. It was measured with the head fully extended on the neck with the mouth closed. A value of less than 12 cm is found to predict a difficult intubation
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LEMON airway assessment method

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INDIAN J. Anaesth. 2003 476 ; 47 (6) : 476-478

Prayer sign

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Wilson and colleagues Developed another scoring system in which they took 5 variables
Weight, Head, Neck and Jaw movements, Mandibular recession, Presence or absence of buck teeth.

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Risk score was developed between 0 to 10.

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INDIVIDUAL INDICES: DIFFICULT MASK VENTILATION

Beard Obesity: BMI > 30 kg/m- risk of DMV. Abnormality of teeth artificial dentures or edentulous. Snorers Elderly

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Anesthesiology, V 98, No 5, May 26 2003

Techniques of Airway Management

Non-invasive -Head positioning -Removal of foreign body -Suctioning -Mask ventilation

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MANAGEMENT OF AIRWAY
Airway

Predicted Normal
Masks

Predicted Abnormal
1. Methods above the cords

Unexpectedly difficult
Failed intubation Drill Failed ventilation drill

LMA
Oropharyngeal airway Nasopharyngeal airway Blind Nasal Intubation Oral Intubation

Blind Nasal intubation

Oral Intubation Intubating LMA Fiberoptic

2. Methods below the cords

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Retrograde methods
Tracheostomy Cricothyroidoct omy
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NONINVASIVE PROCEDURES FOR OBSTRUCTED AIRWAY

Back blow

Manual thrusts
1. Heimlich maneuver(Abdominal thrust)

2. Chest thrust
Head tilt chin lift & Head tilt jaw trust

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Head tilt, jaw trust

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ENDOTRACHEAL INTUBATION
Translaryngeal placement of endotracheal tube is called as endotracheal Intubation

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History : M. Gracia (1805-1906), a singing teacher in London, pioneered indirect laryngoscopy with a mirror. 1895: Alfred Kierstein, 1912: Gustav Killian pioneered direct laryngoscopy 1899: Chevalier Jackson: did his first bronchoscopy and popularized direct laryngoscopy. Edgar Stanley Rowbotham (1890-1979) and Ivan Whiteside Magill (1888-1986) passed tracheal tube via laryngoscope. Edgar Stanley Rowbotham: did first blind nasal intubation
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INDICATIONS:
Respiratory Failure:
Hypoxia, Hypercapnia, tachypnea, or apnea ; ie. ARDS, asthma, pulmonary edema, infection, COPD exacerbation

Inability to ventilate unconscious patient Maintenance or protection of an intact airway Cardiac Arrest
FONSECA VOL 1

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INDICATIONS:
For supporting ventilation during general anesthesia

Type of surgery
Operative site near the airway Abdominal or thoracic surgery Prone or lateral position Long period of surgery Patient has risk of pulmonary aspiration
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EQUIPMENT PREPARATION
ANAESTHESIA AND INTENSIVE CARE MEDICINE 7:10
Equipment for airway management Kathryn Jackson ,Tim Cook

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1) LARYNGOSCOPE : handle & blade

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LARYNGOSCOPIC BLADE:
Macintosh (curved) and Miller (straight) blade Adult : Macintosh blade small children : Miller blade

Mc coy blade

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Miller blade

Macintosh blade

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2) ENDOTRACHEAL TUBE:

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TYPES OF ETTs:
1) Portex tubes:
Semi rigid, with little tendency to kink. Most commonly used.

2) Rubber tubes:
Soft, easily kinked. 3) Reinforced tubes:

- Cuffed or non cuffed. Reinforced with wire to prevent kinking. Double lumen (Robertshaw)

4) Special tubes:
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ENDOTRACHEAL TUBE: (ETT)

1) Size of ETT : internal diameter (ID) Male Female New born - 3 mths 3-9 months 9-18 months 2- 6 yrs > 6 yrs : ID 8.0 mms : ID 7.5 mms : ID 3.0 mms : ID 3.5 mms : ID 4.0 mms : ID = (Age/3) + 3.5 : ID = (Age/4) + 4.5
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2) MATERIAL : Red rubber or PVC

3) ETT CUFF

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High volume Low volume 49 Low pressure cuff High pressure cuff

4) BEVEL 5) MURPHYS EYE

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6) Depth of insertion: Midtrachea or below vocal cord~2 cm

Adult
Male Female ~23 cm ~21 cm

Children
Oral ETT Nasal ETT
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= (Age/2) + 12 (cm) = (Age/2) + 15 (cm)

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OTHER EQUIPMENTS:

STYLET

(malleable)

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OROPHARYNGEAL OR NASOPHARYNGEAL AIRWAY

Oral airway

Nasal airway

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FACE MASK & SELF INFLATING BAG

MAGILL FORCEPS

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LOCAL ANAESTHETIC SPRAY

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PREOXYGENATION:

ventilate with 100 % oxygen for approximately 3 min

Preoxygenation and Prevention of Desaturation During Emergency Airway Management, .2011.10.002

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Sniffing position

Extension at atlantooccipital joint Flexion at lower cervical spine

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STEPS OF OROENDOTRACHEAL INTUBATION

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BAG MASK VENTILATION

C

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HOLDING A LARYNGOSCOPE

Hold the handle of the laryngoscope with your left hand

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OPEN MOUTH TECHNIQUES

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Hyper-extension technique ,Cross fingers techniques

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INTUBATION TECHNIQUE
Introduce the blade into the right side of the patient's mouth move the blade posteriorly and toward the midline, sweeping the tongue to the left and keeping it away from the visual path with the flange of the blade ensure the lower lip is not being pinched by the lower incisors and laryngoscope blade advance the laryngoscope until the 62 epiglottis is in view

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INSERTING THE BLADE

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INTUBATION TECHNIQUE
lift the laryngoscope upward and forward insert the ETT from the right angle of mouth with its concave curve facing downward and to the right side of the patient maneuver the endotracheal tube into the larynx, midway between the cricoid cartilage and the sternal angle

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LIFTING UP A LARYNGOSCOPE:

Pull the blade forward and upward using firm but Steady pressure without rotating the wrist Avoid leaning on the upper teeth with the blade
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BURP Maneuver:
ON THYROID CARTILAGE Backward: against the cervical Vertebrae Upward

Right: lateral pressure to the right

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ROLE OF AN ASSISTANT
To provide the endotracheal tube to the operators right hand To apply circoid pressure Facilitates intubation using BURP maneuver

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INTUBATION TECHNIQUE
inflate the cuff and apply positive pressure ventilation while the assistant auscultates secure the endotracheal tube in position after b/l equal air entry is confirmed

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CONFIRMATION :

By Physical Exam

Confirm tube placement immediately Listen over the epigastrium and observe the chest wall for movement If stomach gurgling and no chest wall expansion esophagus intubated: deflate the cuff and remove ET tube Reattempt intubation after re -oxygenation
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CONFIRMATION: CONTD.
If chest wall rises and stomach not gurgling, perform 5-point auscultation If still doubt, use laryngoscope to see the tube passing through the vocal cords (best) Secure the tube Look for moisture condensation on the inside of the tracheal tube (not 100%: false +ve with esophageal intubations)
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